Failure to Complete Required PASRR Screenings and Evaluations for Residents With Mental Illness
Penalty
Summary
The facility failed to ensure required Preadmission Screening and Resident Review (PASRR) processes were completed prior to or in conjunction with admission for multiple residents with mental health diagnoses. One resident with depression and anxiety was admitted with a Level I PASRR screen indicating serious mental illness, but the required Level II evaluation was never completed. Another resident with major depressive disorder also had a Level I screen showing indicators of serious mental illness, yet no Level II evaluation was performed. A third resident with depression and anxiety did not have a Level I PASRR screening completed until several weeks after admission, rather than prior to admission as required. In addition, a resident with depression was admitted under a 30‑day hospital exemption and had a Level I PASRR screen that did not indicate the need for a Level II evaluation. This resident remained in the facility beyond the 30‑day exemption period, but a new PASRR screening and Level II evaluation were not completed after the exemption expired. During an interview, the Social Services Director, who began employment in July 2025, stated they were not aware that PASRR screens and Level II evaluations were required to be completed before residents were admitted, and acknowledged the importance of incorporating evaluator recommendations into the care plan and providing behavioral health services.
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